Professor El-Omar has selected Dr David Beaton, Northumbria Healthcare NHS Foundation Trust, North Shields, UK to do the next #GUTBlog. Dr Beaton is the first author on this paper.

The #GUTBlog focusses on the paper “Diagnostic yield from symptomatic gastroscopy in the UK: British Society of Gastroenterology analysis using data from the National Endoscopy Database” which was published in paper copy in GUT in September 2024.

Dr Beaton writes about the paper below:

“At first glance, the role of gastroscopies appears straightforward. Therapeutic gastroscopy is essential for treating various gastrointestinal (GI) issues, such as upper GI bleeds and strictures, and histological confirmation remains crucial for diagnosing conditions like cancer and eosinophilic oesophagitis. However, beyond these applications, its role becomes more questionable. For instance, the survival benefit from Barrett’s oesophagus screening is minimal, and coeliac disease can be reliably diagnosed through serology tests.

Additionally, most of the million or so gastroscopies performed annually in the UK are performed to investigate upper GI symptoms, essentially to screen for cancer. However, despite the ever-increasing number of these procedures, outcomes for oesophageal and gastric cancers have shown little improvement. Interestingly, during the COVID-19 pandemic, deaths from colorectal cancer rose following the suspension of elective colonoscopies, yet there was no corresponding increase in deaths from oesophageal or gastric cancer. This discrepancy raises important questions: Why are cancer outcomes not improving, and can we alter our practice to overcome this?

In response to the first question, the link between upper GI symptoms—excluding dysphagia—and upper GI cancers is weak and when symptoms do eventually present, the cancer is often too advanced for effective treatment. Despite this, substantial resources continue to be allocated to investigating these symptoms. The motivation behind this is rooted in a genuine desire to help. Medical training has instilled in healthcare professionals the belief that symptoms indicate a higher risk of pathology. However, emerging evidence, including our current results, suggests that this conventional wisdom is flawed. We must also consider potential self-interest. Gastroenterology, once considered an unglamorous specialty, is now among the highest-paid fields in the United States, with endoscopy playing a central role in this transformation.

Many healthcare professionals argue for the benefits of a cancer-negative gastroscopy result, as it can alleviate anxiety and rationalise medication use. However, these benefits come with significant costs. Perhaps the most concerning long-term cost is that advocating for the status quo hinders efforts for improvement. By maintaining current practices, we ultimately fail patients with oesophageal or gastric cancer.

Should we simply stop performing symptomatic gastroscopies and accept the poor survival rates for oesophageal and gastric cancers? Absolutely not. Instead, we need to strive for improvement, which requires a fundamental shift in how we approach and utilise gastroscopy. One potential path involves adopting a more selective approach, focusing on high-risk patients and conducting longer, higher-quality examinations to help ensure that subtle pathology is detected. This strategy could reduce missed cancers and identify more pre-cancerous changes, potentially improving outcomes through earlier diagnosis.

Identifying this high-risk cohort remains a significant challenge. To address this, we urgently need less- or non-invasive methods to better define this population, similar to how FIT or calprotectin are used in the lower GI tract. Investing in these diagnostic advancements would be a more effective long-term use of resources than continuing the largely futile practice of routinely performing gastroscopies for low-risk symptoms.

In conclusion, the current reliance on gastroscopy for symptom investigation requires a thorough re-evaluation. By adopting a more nuanced approach and embracing innovative diagnostic techniques, we can better serve our patients and ultimately improve outcomes for those suffering from oesophageal and gastric cancers. The goal is not to discard gastroscopy but to refine its use, ensuring it is employed in a way it can truly make a difference.”

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